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Cardiology 2 > Arterial Vascular Disease > Flashcards

Arterial Vascular Disease Flashcards

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1
Q

Four main arterial vascular diseases and one minor

A
  • Giant cell Arteritis
  • Polymalgia Rheumatica
  • Arterial Insufficiency
  • Peripheral Arterial Disease
  • Aortic Aneurysm/Dissection
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2
Q

Giant Cell Arteritis

  • aka
  • who does it affect
  • what can it cause
  • how treat
A
  • temporal arteritis
  • primarily people over 50
  • blindness
  • high-dose steroids
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3
Q

Polymyalgia rheumatica

  • who does it affect
  • what other dz is it associated with
  • how treat
  • where see sx on body
A
  • primarily people over 50
  • 50% pts with giant cell arteritis have polymyalgia rheumatica
  • low dose steroids
  • sx below the neck
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4
Q

Pathophysiology of GCA

A
  • exact etiology unknown
  • theories: age, ethnicity, genetic disposition (maladaptive response to endothelial injury= inappropriate activation of cell-mediated immunity)
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5
Q

What is the progression of GCA

A
  • vessel wall damage
  • intimal hyperplasia
  • stenotic occlusion
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6
Q

What blood cell is seen in GCA

A

eosinophils

- likely but not always high WBC

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7
Q

GCA

  • which vessels are affected
  • epidemiology
A
  • medium and large arteries, most often the temporal artery
  • older than 50, mean age 72
  • Women > men
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8
Q

GCA

classic presentation

A
  • HA (temporal region)
  • scalp tenderness
  • vision: loss of sight in one eye, diplopia
  • jaw claudication
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9
Q

what is the highest positive predictive value sx for GCA

A

jaw claudication

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10
Q

GCA

Non-classic sx

A
  • dry cough (inflammation of aortic arch)
  • mononeuritis multiplex, often in shoulder
  • idiopathic fever
  • > 65
  • normal WBC
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11
Q

GCA

- how does blindness occur

A

occlusive arteritis of posterior ciliary branch of the ophthalmic artery

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12
Q

Timing of funduscopic findings in GCA

A

might not appear in first 24-48 hours

**don’t rely heavily on funduscopic exam for dx

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13
Q

GCA

- PE head findings

A
  • scalp tenderness
  • temporal artery can be normal, nodular, enlarged
  • erythema, warmth, swelling
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14
Q

GCA

- PE eye findings

A
  • iritis, fine vitreous opacities
  • optic nerve edema
  • swollen, pale disc with blurred margins
  • pallor
  • hemorrhage
  • scattered cotton-wool spots
  • vessel engorgement/exudates later in dz
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15
Q

GCA

- lab findings

A
  • ESR (90% >50mm/h, typically see >100mm/h)
  • CRP
  • CBC (mild normochromic anemia, thrombocytosis, WBC normal or elevated)
  • Elevated liver function tests, PT
  • NL CPK, renal fn, UA
  • Elevated interleukin-6 during flairs
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16
Q

ESR vs CRP - which is more sensitive for GCA

A

CRP is slightly higher

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17
Q

GCA

- imaging

A
  • doppler US to show vascular occlusion, stenosis, edema
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18
Q

What is GCA gold standard for dx

A

temporal artery biopsy (min length 2 cm d/t incidence of skip lesions)

  • will see giant, multinucleated cells
  • do contralateral biopsy if suspicion is high but first biopsy was negative
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19
Q

GCA

- Treatment

A
  • 1st line: HIGH dose steroids
  • rheumatology and neuro referral
  • consider ASA to avoid clots
  • PPI for GI protection
  • Ca2+, Vit D, bisphosphonate for bone protection
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20
Q

GCA

- major complications (3)

A
  1. irreversible blindness
  2. aortic aneurysms
  3. polymyalgia rheumatica
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21
Q

Polymyalgia Rheumatica

  • describe
  • 3 common sx and pertinent negative
  • pts won’t be able to do what
A
  • pain and stiffness below the neck
  • fever, malaise, weight loss, NO muscular weakness
  • pts will have trouble combing hair, putting on coat, getting out of chair
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22
Q

Polymyalgia Rheumatica

- two common lab findings

A
  • anemia
  • elevated ESR
  • most, not all cases
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23
Q

Polymyalgia Rheumatica

- treatment

A
  • LOW dose steroids
  • no improvement in 72 hours f/u
  • flair ups can occur
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24
Q

What sx should cause you to put GCA in differential

A
  • > 50
  • HA
  • Jaw claudication
  • fever
  • vision changes
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25
what medical hx might find with GCA
DM Cardiac dz HTN
26
Thrombus/thrombi def
clot (platelets and/or fibrin) that forms and is stationary in vessel
27
embolus/emboli def
piece of thrombus breaks off and travels through bloodstream until it gets stuck (can be plaque, fat, air, etc.)
28
Thromboembolism
clot formed in blood vessel and breaks loose, carried by blood stream until gets stuck in another vessel
29
Arterial insufficiency - def - acute, chronic, or both?
- loss of perfusion - distal to occlusion of major artery due to embolus - acute AND chronic
30
Arterial insufficiency | - secondary to what
- emboli - thrombosis - trauma - infection - inflammation
31
Arterial insufficiency | - epidemiology
- >65 - male - More common in AA
32
Arterial insufficiency | - leading cause of what in the elderly
limb loss
33
Arterial insufficiency | - risk factors
- Tobacco use (vasoconstriction) - endocarditis (clots from affected valves) - DM - drug abuse - cardiac arrhythmia (most likely a fib) - atherosclerotic dz - trauma
34
Arterial insufficiency | - how is genetics related
can be associated with inheritable hyper coagulable states and premature atherosclerotic syndromes
35
Arterial insufficiency will cause what in the: | - Heart
chest pain | MI
36
Arterial insufficiency will cause what in the: | - Brain
weakness | CVA
37
Arterial insufficiency will cause what in the: | - LE
severe claudication | PAD
38
Arterial insufficiency will cause what in the: | - Mesenteric arteries
- pain after eating - pain out of proportion to exam - MAI (mesenteric artery ischemia)
39
Arterial insufficiency will cause what in the: | - Renal arteries
CVA tenderness | RAI (renal angina index OR renal artery ischemia)
40
Arterial insufficiency | - four classifications
1. Asymptomatic - ex. DM 2. Claudication - inadequate blood flow during exercise 3. Critical limb ischemia - compromise of blood flow to extremity, limb pain at rest. Often ulcers or gangrene 4. Acute limb ischemia - sudden decrease in perfusion that threatens limb viability
41
What is associated with acute limb ischemia
5 P's - pain - paralysis - paresthesia - pulselessness - pallor
42
Arterial insufficiency | - Lab tests
- CK/CKMB/Troponin - PT/INR, PTT - ABG - look for acidosis - CBC, CMP - UA - Lipids - atherosclerosis - ESR/CRP
43
Arterial insufficiency | - Imaging
- CT angiography - arteriography - EKG - ECHO - Doppler US - ankle/arm index (AAI) *unequal blood pressure - ankle/brachial index (ABI) *unequal blood pressure
44
Arterial insufficiency | - treatment
- Heparin (not coumadin, takes too long) - Thrombolysis (stent, PTCA, etc.) - Angioplasty - Stenting - Endarterectomy - peripheral bypass sx
45
Arterial insufficiency | Major treatment goals
1. don't let it get worse, "thin" blood | 2. if occluded, return blood flow around or through
46
Absolute contraindications for thrombolytic therapy (6)
1. recent major bleeding 2. recent stroke 3. recent major surgery or trauma 4. irreversible ischemia of end organ 5. Intracranial pathology 6. Recent ophthalmologic procedure
47
Relative contraindications for thrombolytic therapy (5)
1. Hx of GI bleed or PUD 2. Coagulopathy 3. Uncontrolled HTN 4. Pregnancy 5. Hemorrhagic retinopathy
48
What sort of onset is Arterial insufficiency
Always sudden
49
Peripheral arterial disease | - def
- systemic arterial atherosclerosis with partial/total blockage in the arteries. Exclusive of the coronary and cerebral vessels - resting ankle-brachial index (ABI) <0.90
50
Describe peripheral arterial disease
- arterial stenosis secondary to atherosclerotic plaque formation - plaque formation causes inadequate blood flow in distal limbs - fail to meet metabolic demand during exertion - acidic products build up and result in claudication - also causes distal pressures
51
Most common arteries affected by PAD
- superficial femoral - deep femoral - popliteal arteries 80-90% (tibial and fibular/peroneal arteries 40-50%)
52
Intermittent claudication | define
- reproducible discomfort within a defined group of muscles that is induced by exercise and relieved by rest - Sx resolve 2-5 min after pt rests - leg pain worse when raise leg - leg pain better with pt lowers leg
53
Peripher arterial disease | - 5 common findings
1. intermittent claudication 2. erectile dysfunction 3. leg/foot weakness, numbness, tingling 4. skin changes - ulcers that won't heal 5. gangrene
54
Peripheral artery disease | - Fontaine stages of classification
Stage 1: asymptomatic Stage 2a: intermittent claudication after 200 meters no pain Stage 2b: intermittent claudication after <200 meters walking Stage 3: rest pain Stage 4: Ischemic ulcers/gangrene
55
Peripheral artery disease | - Diagnostic labs
- check for co-morbidities: serum glucose or HgbA1c | - fasting lipid profile
56
Peripheral artery disease | - imaging
- duplex ultrasonography and doppler color-flow imaging - contrast angiography - CT angiogram - MR angiogram
57
what is the best imaging option for Peripheral artery disease
contrast angiography
58
Peripheral artery disease | - other tests
- Ankle branchial index <0.90 - Toe brachial index <0.6 - segmental limb pressures - treadmill exercise tests - segmental volume plethysmography :)
59
Peripheral artery disease | - treatment goal
- improve quality of life - improve walking capacity - decrease morbidity/mortality
60
Peripheral artery disease | - lifestyle changes
- smoking cessation - diet - exercise - control blood sugar - control HTN - decrease lipids - foot care/appropriate shoes
61
Peripheral artery disease | - pharm tx
- Antiplatelet - Clopidogrel - Ticlopidine - prostaglandins - statins
62
Peripheral artery disease | - intervention tx
- bypass sx | - PTCA w/wo stent placement
63
Peripheral artery disease graft treatment | 4 common complications
- graft occlusion - infection - massive bleeding - limb loss
64
Peripheral artery disease | - PTA (PTCA)
- less invasive - lower procedure risk - lower cost - preserves sx option if needed later - improves latency rates with stent vs. angioplasty alone
65
What is appropriate 1st line tx for aortoiliac obstructive dz
PTA (aka PTCA)
66
Complications of PTA
- groin hematoma - pseudoaneurysm - AV fistula formation - distal embolization - thrombotic occlusion - arterial rupture
67
Aortic Aneurysm Disease | - two types
- Fusiform: whole circumference or wall of artery | - saccular: not full circumference, asymmetrical bleb or blister on side of aorta
68
Four types of Aortic Aneurysm Disease
- suprarenal - pararenal - juxtarenal - infrarenal
69
Aortic Aneurysm Disease | - epidemiology
- >50 | - Males 5: females 1
70
Aortic Aneurysm Disease | - risk factors
- older age - male - family history (1st degree relative) - smoking - HTN - Hyperlipidemia - PVD - obsesity - Marfan - Ehlers-Danlos - polycystic kidney dz
71
Aortic Aneurysm Disease | - etiology
- Atherosclerosis (80%) - inflammatory dz (5%) also: - trauma - connective tissue disorders - infection
72
Aortic Aneurysm Disease | - pathophysiology
- vascular inflammatory degenerative dz - gradual/sporatic expansion of aneurysm - accumulation of mural thrombus - localized hypoxia further weakens aneurysm - tend to expand over time
73
Aortic Aneurysm Disease | - patient sx
- severe abdominal pain radiating to lower back - gnawing, burning - CONTINUOUS
74
Aortic Aneurysm Disease | - PE findings
- pulsatile supraumbilical mass - vague abdominal tenderness with palpation (30-40% detected by PE)
75
Aortic Aneurysm Disease | - what can the aneurysm encroachment cause?
- vertebral body erosion - gastic outlet obstruction - ureteral obstruction
76
What secondary issue can occur with Aortic Aneurysm Disease
- lower extremity ischemia secondary to embolization of mural thrombus
77
Aortic Aneurysm Disease | - labs
- CBC - CMP - UA - Amylase (pancreatic enzyme) - Lipase (pancreatic enzyme)
78
Aortic Aneurysm Disease | - imaging
- US - CT angiography - MRI/MRA - Abd xray - aortography
79
what is best imaging option for sizing/preop planning, what is its downside
CT angiography | - downside is requires contrast, problem with renal failure
80
Aortic Aneurysm Disease | - pharm tx
- BB - Statin - ASA - smoking cessation, lipid control, diet, exercise
81
Aortic Aneurysm Disease | - surgical tx
- open repair: good or average surgical candidates | - Endovascular Aortic Repair (EVAR): high risk pts d/t co-morbidities
82
Compare EVAR and open repair
- similar survival rates - EVAR has less short-term complications - EVAR has more long term complications (thrombosis)
83
Aortic Aneurysm Disease | - elective repair threshold size
- 5.5 cm average pt - 5 to 5.4 cm younger, low risk pts with long life expectancy - 4.5 to 5 cm women or high risk of rupture
84
Aortic Aneurysm Disease | - factors of high risk for rupture
- expansion of > 0.6 cm/year - smoking, severe COPD, steroids - family hx - HTN poorly controlled - shape is non-fusiform
85
Aortic Aneurysm Disease | - also have CAD, what should do before aneurysm repair
consider coronary revascularization
86
Aortic Aneurysm Disease | - screening
- one time US in men 65-75 who have ever smoked - Men >60 with fam hx * not for women bc risk so much lower than men
87
Aortic Aneurysm Disease | - Triad indicative of rupture
- hypotension/shock - pulsatile mass - abd pain
88
Aortic Aneurysm Disease rupture tx
immediate vascular surgery consult - IV access and resuscitation - type and cross for multiple units - bedside US - endovascular AAA repair
89
Thoracic aneurysm disease | - parts of aorta
- aortic root - ascending aorta - descending aorta
90
Thoracic aneurysm disease | - hx/PE findings
- most detected incidentally - Aortic insufficiency - early diastolic murmur, heart failure - cough, dysphagia, hoarseness
91
Thoracic aneurysm disease | - imaging
- CXR - CT Angiogram - MRA - Aortography - TTE/TEE
92
Thoracic aneurysm disease | - CXR findings
- loss of aortic knob | - widened mediastinum
93
What is most common imaging for Thoracic aneurysm disease
CT Angiogram | - excellent anatomical detail and sizing
94
Thoracic aneurysm disease | - sx treatment
- open repair in proximal TAA | - thoracic endovascular aortic repair (TEVAR) in descending aorta
95
Thoracic aneurysm disease | - non surgical tx
- low-normal BP via BB, ARBS, ACEI | - annual surveillance imaging
96
Aortic dissection | - def
begins with a tear in aorta intimal, blood enters media, divides it into two layers
97
Aortic dissection | - pathophysiology
- tear in aortic intima is likely precipitating factor - aortic media degenerates - dissection can extend distally and proximally (can involve aortic valve and branch vessels) - progression - tamponade, ischemia of vessels - communications might form between true and false lumen
98
Aortic dissection | - risk factors
LOTS - HTN - tobacco - marfan - etc etc etc
99
Aortic dissection | - sx
- acute chest pain "ripping, tearing" - back or abd pain - syncopal episodes - distal ischemia
100
Aortic dissection | - signs
- cardiac tamponade - hemothorax (L > R bc heart is on left) - >20 mmHg diff in systolic pressure btwn arms - neurologic deficits - renal insufficiency
101
Aortic dissection | - Diagnostic imaging
- CT scan - Aortography - MRI - TEE
102
Aortic dissection - auto admission where? - pain control via what? - BP and HR tx
- ICU - morphine - reduce systolic BP to 100-120 or lowest tolerable - HR <60 **goal is to reduce aortic shear stress
103
Aortic dissection | - pharm tx
- IV beta blockers (Esmolol is best bc drip and short half life makes titration easier) - Cardioselective CCB (Verapamil and diltiazem) - direct vasodilators
104
Aortic dissection | - what is definitive tx?
surgical repair

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